"In the future, clinicians will have the choice on the blend between physical, virtual, and automated care that they can prescribe."

Q. With the pandemic, mental health and social care, have become even more integral to care delivery in the US. Virtual visits initially skyrocketed and then, fell, slightly. In this context, can you share the State of the Union on Telehealth in the US, today?

Roy: The COVID-19 pandemic made a lot of people realize that health care can be delivered safely and effectively over technology. Maybe that’s the highest way of describing it. While that statement is true, it resonated differently with diverse audiences and impacted them differently. We’ve seen many Americans — patients, consumers, members — gravitating towards telehealth because during the pandemic, movement was restricted. So, there was a huge increase in adoption of telehealth by the general population. When the situation improved, the same volume of health care needs started getting balanced by telehealth, retail clinics, ERs and Physicians’ offices. Today, there is a higher volume of telehealth, but it’s definitely come down compared to earlier.

The part that’s less reported but has lasting impact is the adoption of telehealth by the clinicians. Their reasons are very different — Most health systems and offices couldn’t see patient volume, couldn’t submit claims and were experiencing financial upheaval. So, many organizations systematically started shifting a lot of the health care onto telehealth to restore their ability to do business. That created a circumstance where a lot of clinicians were exposed to it for the first time and they liked it. What is really astonishing about the long-lasting effects of the pandemic is that the volume of telehealth on our system being carried out by clinicians with their own patients, continues to grow. So even though, things have hopefully subsided and the critical moment is past, telehealth now has a life of its own – like a viral evolution. I think we’re just at the beginning of understanding how that’s going to affect our experience as patients in the future.

Q. Have we reached an equilibrium or are we still in an exploratory stage? Is this going to play-out over a long time?

Roy: We haven’t even begun to scratch the surface. We may have just passed a point where people are asking — should we be using telehealth? That point is in our rearview mirror. People are starting to wonder how to utilize it effectively. “How can I make life easier for my patients? How can I make it easy for them to be compliant with a medical regimen that they need? How can I move the needle on cost of health care using technology?”

All of these conversations are now being held, but they’re still very nascent. So, I think the world is actually going to change for telehealth much more drastically over the next couple of years, paradoxically, than what it did during the during the pandemic.

Q. Who have you primarily served as payers — providers, employees? How has it changed predisposition to a pandemic?

Roy: That’s a fascinating question. So, we’re a little different at Amwell given we’ve built more of a platform and technology infrastructure. The result was that we could do a lot of business in each of these verticals. We run telehealth for a lot of the payers – regional and national. We run a lot of telehealth for health systems and serve many other institutions, individual clinicians, the government etc. That gave us an interesting lens into how things have changed over the last two years, because the appetite and motivation for telehealth had dramatically changed within those different organizations or verticals. For instance, if historically, the payers and the peers were thinking about telehealth as a way to get people to not use ERs, that was the big-ticket item.

How do you ensure that people have an alternative when there’s something wrong with them so they don’t have to go to very expensive and overutilized ERs? While this still remains a calling for telehealth from the perspective of the payroll, the health plans actually think of it more as an instrument to influence the care being rendered to a patient at the point of care. This is where virtual PCP etc. come into play. But payers are beginning to utilize telehealth and its ability to incorporate data in real-time because it’s a digital platform. This incorporates the best analytics, the best network definitions to ensure that the care being rendered to the patient is much more informed and cost-effective. This has major implications on how much must be spent on insuring those patients. This, then, is a radical transition in the understanding of what these technologies can do. And it’s true for every domain, not only payers.

Q. When you talk to your customers today, it’s a part of the conversation. What are the top two or three things you hear in the context of the imminent digital transformation?

Roy: The conversation is a little different depending on the type of the customer being spoken to – the payer, the health system – it isn’t exactly the same. But, in terms of similarities, the general notion is we need to transition a lot of the care that we’re involved in, to digital platforms. The motivation and the instruments by which this happens are different when you talk to a health system — it’s really more about making this the second language for clinicians because they’re the ones calling the shots and prescribing care. We need to make it very easy for them to take advantage of these technologies. From there, you can peel the onion.

It needs to be integrated into their research, scheduling and their staff needs to be able to help them with patient interactions. They must be able to move seamlessly from the physical to digital to physical between 10 and 11 a.m., for instance. So, there’s a whole list of derivatives that are driven by health systems to make telehealth a channel of health care delivery for themselves.

When you talk to health plans, it’s the same motivation — to move as much of the delivery of care to those digital platforms, as possible. The other questions are – How do we implement access so that it is top of mind of our membership? How do we make it easier to consume given there’s so much variability at the consumer level? How do we make sure that it will operate cleanly in the same way on any platform that they want to utilize? How do we ensure that the employers that essentially govern the communication mention the benefits to the employees and pass this along in their messages?

It’s a very different kind of currency and different instruments, but they all have one endpoint — health care activity needs to transfer over technology. People may attribute different percentages to this –20-25% — and it’s still a nimble kind of aspiration. If you think that more than 50% of retail has already transitioned into technology, that’s it.

Q. There are challenges as well. Provider adoption. Systems integration. And then, are consumers willing to go with a virtual first kind of a model? What are the health systems doing or should be doing to make this more of a default mode of operation for the clinician community who are by far the most important stakeholders in patient care?

Roy: I don’t envy anybody’s job of trying to bring change into the way that clinicians practice. That is a very tough nut to crack. And not because clinicians are bad people but because there’s just so much that they need to do that any learning curve, any variation, is trouble.

While I love technology, and it has a huge role to play, the parameter that makes the most difference is leadership. Technology must be integrated and accessible, predictable and reliable but at the end of the day, people — and clinicians — need to subscribe to why they would make that effort. In our experience, organizations that had exceptional leadership took the time to explain why this was going to be part of the vocabulary and the way to envelop all patients in the future.

The sooner we take advantage of it, we’ll become not only more modern but will be able to really serve our mission of delivering better health care and hope. That is sometimes lost when you talk about system integration and APIs etc. I’d say it has a bigger impact than people usually attribute to it. You are creating a perfect storm because if you do the right thing, you create expectations. Then the expectations are, if one signs up for it, it will work. It won’t be a hindrance to patient care, won’t get one to cancel visits because the patient wasn’t able to sign-in on the other end. So, there’s a lot of technology, work and detail you need to go through to live-up to the promise but it comes down to whether clinicians can absorb the huge impact that this is going to have on patients’ lives and as a result, the way they practice medicine.

Q. Economists mention incentives. With regard to the reimbursement environment for telehealth, where are regulators going with the reimbursement models? How big is this factor? Are there uncertainties people are overcoming in this context? Where are we right now?

Roy: We’ve turned a corner in the sense that nobody paid significant attention to changing reimbursement in a meaningful way prior to COVID. Now again, that question of whether it needs to be changed is behind us.

People understand that the new models of reimbursement have to include enabling clinicians to use technology where they estimate it’s for the good of the patient. It’s tough because it’s a whole new language. When CMS was considering a new zip code or the level of reimbursement for that zip code, it was a ritual that they’d repeated for many years. This one though, is big. You’re talking about how the entire practice of medicine can be rendered in completely different care settings. It really depends on how tech-savvy the patient is, which is really not a parameter in a medical chart. So, it is somewhat of a challenge.

If we’d discussed that question two years ago, I’d have said it’s a strategic challenge for the industry. I think that now, it’s a tactical challenge. There’s little doubt that within the next three to five years, the reimbursement issue is going to be behind us. I think that train has left the station. It’s still annoying and confusing because who knew health care could be so complicated? Where we’re going to end up is — clinicians are going to have the choice on the blend between the physical, the virtual and the automated so they can prescribe to a patient based on who the patient is and what they think is right.

Q. Amwell’s been in the news for the acquisition of SilverCloud and Conversa! What was the rationale? What should your clients and their clients expect next year?

Roy: The biggest impact was a new understanding of where these technologies could help health care. It’s not a question of “if” anymore, it’s “how.” And the understanding that it’s kosher to use technology to surround patients, opened the door to a lot more than just video-visits. People are not even talking about clinicians but have higher receptivity to the fact that some of their health care is going to be done in an office or in a hospital, some through their phone or the television or whichever one they choose. There is a deeper subtlety here — that is critically important, and that ties into the acquisitions — which is, we now have the opportunity to completely rethink how we surround patients. I’m not talking about the transactional people with the flu or a rash but when we think about the patients that really consume the health care dollars — people with chronic conditions, elders, cancer patients etc., it is now a legitimate conversation.

Can we surround them more holistically? Can we be present in a much more effective way than physical health care allowed? Physical health care was present next to a patient when they showed up in the office. When they left the office, they were on their own with a lot of guidance and prescriptions. Technology allows us to rethink the presence of health care around patients. We can be omnipresent. The real question is — how can technologies interact with the patient more automatically? How can we use A.I., NLP and algorithms to be there with the patient when they wake up in the morning? Maybe via a text message that says, “Hey! Did you take your medications this morning? What’s your pain level? Are you out of bed?”

There’s a whole world that opened up with the automated presence of health care around patients and if it is tied correctly to the synchronous clinician-based care for the patient, it can actually be incredibly powerful. Both of the acquisitions that we’ve made are along those lines. SilverCloud offers infrastructure for automated companionship with patients with behavioral health issues, patients who are depressed, anxious, suffer sleeping and eating disorders. There’s a variety of those in Conversa. That’s a very powerful automated infrastructure for companionship with patients along the line of medical conditions — patients who are coming in and out of a hospital, have chronic conditions etc.
We’re now beginning to form a pretty formidable automated encapsulation of patients who have those kinds of conditions. And we’re plugging it together with our fairly significant assets by way of virtual interaction with those patients. Conversa detects that something is going wrong with that patient. It has the ability to summon the truth. It’s connected to the telehealth of our world to bring clinicians in. And we are already connected into the physical world of health care through our integration with all these different health systems and payers.

So, there is the promise of completely reimagining how we approach long-term patient management — the trifecta of physical, virtual and automated care. That was the reason for the acquisition. And that’s the vision.

Q. You’ve described what many Chief Digital Officers (CDOs) are trying to do — surround the patient with technology and a seamless experience. The second part is more challenging – the plethora of technology platforms that can go into a digital roadmap forward. In that context, what is your advice for CDOs?

Roy: We have to acknowledge that we’re not trying to create another health care system. We’re trying to connect the parts and allow different organizations to do the best they can in the context of that kind of holistic, continuous patient experience. Health plans should continue to be health plans and health systems and clinicians will continue to be clinicians. The technologies are just going to give them wings to be available and deliver to a broader population in a more timely and equitable fashion.

While I’m not sure the answer is to have one system, you have to have an EHR and an interactive telehealth system. And they’re both foundational capabilities that must be developed so they speak to each other fluently. One piece of advice I have is — a big part of the way that you care for patients is going to go over technology and that is inevitable. The moment that you take a step back and think of the future, that’s where things will be clear in terms of the infrastructure that you’ll need and how to plug one thing into the other.

Q. Recent newspaper reports speak of big tech firms – Google and Apple, for instance — scaling back some of their programs. What does that say about the nature of the state and the nature of the beast?

Roy: I think it’s different. The biggest challenges in health care are that the consumer doesn’t know what they’re buying and the provider doesn’t know what it costs. The health plan and who pays for it, is nowhere near where care is being rendered. But that doesn’t mean that you can’t be a part of the solution. Sometimes, in large companies, being part of a solution is not necessarily in line with the way you view yourself. While that is humbling, we all have a role to play and eventually we’ll find our places for it’s an ecosystem and not one person’s landgrab.

Q. One last question — you’re very familiar with information security and ransomware attacks so what’s your view of what’s going on? What’s going to get worse before it gets better?

Roy: I don’t want to end with a somber statement. But I shall say that it’s going to get worse simply because so much of health care is transitioning into digital channels and health care is near and dear to people’s livelihoods and pockets, almost like their bank accounts. We already know that medical records are worth more in the cyber black market than a credit card number. So, there will be more attacks, people with interest to disrupt, will steal data. That just means that you need to be very serious about the infrastructure being put in place — Information Security and all of its aspects will need to be from the floor-level of system design and they should not be one-time investments. It’s a long-term battle with the bad guys – they aren’t going away so we can’t, either. We just need to accept this as the way forward and carry on.